Association between Longer Travel Distance for Transplant Care and Access to Kidney Transplantation and Graft Survival in the United States

Abstract

BackgroundTransplant candidates may gain an advantage by traveling to receive care at a transplant center that may have more favorable characteristics than their local center. Factors associated with longer travel distance for transplant care and whether the excess travel distance (ETD) is associated with access to transplantation or with graft failure are unknown.MethodsThis study of adults in the United States wait-listed for kidney transplantation in 1995–2015 used ETD, defined as distance a patient traveled beyond the nearest transplant center for initial waiting list registration. We used linear regression to examine patient and center characteristics associated with ETD and Fine–Gray models to examine the association between ETD (modeled as a spline) and time to deceased or living donor transplantation or graft failure.ResultsOf 373,365 patients, 11% had an ETD≥50 miles. Traveling excess distance was more likely among patients who were of non-Black race or those whose nearest transplant center had lower annual living donor transplant volume. At an ETD of 50 miles, we observed a lower likelihood of deceased donor transplantation (subhazard ratio [SHR], 0.85; 95% confidence interval [95% CI], 0.84 to 0.87) but higher likelihood of living donor transplantation (SHR, 1.14; 95% CI, 1.12 to 1.16) compared with those who received care at their nearest center. ETD was weakly associated with higher risk of graft failure.ConclusionsPatients who travel excess distances for transplant care have better access to living donor but not deceased donor transplantation and slightly higher risk of graft failure. Traveling excess distances is not clearly associated with better outcomes, especially if living donors are unavailable.

Listing at non-local transplant centers is associated with increased access to deceased donor kidney transplantation

“…However, in their study, travel was associated with a higher rate of living donor transplant, but a lower likelihood of deceased donor transplant, which is in contrast to our findings. 10 In a sensitivity analysis, we calculated ETD as was done in that study and found that a higher ETD was associated with a higher likelihood of deceased donor transplant in our cohort, consistent with our main analyses. One likely explanation for the differences observed Another potential explanation for the increased access to deceased donor transplant attained by travelers in the post-KAS era is the way that we handled multiple listings in analyses.…”

“…To facilitate comparison of our result to prior studies that have examined similar outcomes using geographic distance, rather than TRR catchment areas, we conducted a sensitivity analysis using excess travel distance (ETD) as the travel metric, as has been previously described. 10 We calculated the distance from the patient's home ZIP code to the closest active adult transplant center (>25 waitlist registrations for patients older than 18 in the study period) and the distance to the center at which the patient was listed. To calculate ETD, we subtracted the distance to the closest center from the distance traveled.…”

“…5,6 However, the ability of patients to select and travel to centers with higher transplant rates may vary by sociodemographic factors and contribute to pre-existing disparities in transplant access. [7][8][9] Prior studies have used one of two main approaches to define travel: geographic distance [10][11][12] or travel to a different donor service area (DSA). 13 Defining travel using distance, often the distance from a patient's home ZIP code to their transplant center, may conflate the effects of barriers in the physical distance that a patient lives from a center with other barriers, including the cost and burden of travel.…”

“…Prior studies have used one of two main approaches to define travel: geographic distance 10–12 or travel to a different donor service area (DSA) 13 . Defining travel using distance, often the distance from a patient's home ZIP code to their transplant center, may conflate the effects of barriers in the physical distance that a patient lives from a center with other barriers, including the cost and burden of travel.…”

A scoping review of inequities in access to organ transplant in the United States

“…Determinants of delays in time to transplantation differed substantially by racial/ethnic group [ 192 , 193 ]. A decreased likelihood of deceased donor transplantation was also associated with long travel distances to the transplant center [ 194 ]. VA-insured and Medicare/Medicaid-insured patients were less likely to be placed on the waitlist and less likely to receive transplants than patients with private insurance.…”